The Francis Report: Why the World Should Listen

Edward Maile

Medicine in the 21st century continues to advance and bring unprecedented benefits to patients. Many people across the world now have access to safe, high quality healthcare. However, even in the world’s leading healthcare systems, patients still experience needless suffering and harm. This was exemplified by the recent Francis inquiry, which investigated care delivered at Stafford Hospital, a facility in the UK’s National Health Service, between 2005 and 2009.1 In brief, the report found that large numbers of patients were dying due to poor care. Many were denied even basic dignities such as food, water and sanitation. It may be tempting to dismiss this as a unique episode which is unlikely to occur elsewhere. However, I believe the report has global relevance, and that clinicians the world over can learn important lessons from its findings.

What Happened at Stafford Hospital?

The authorities were initially alerted to the standard of care at the hospital by the abnormally high mortality rates relative to the national average. This led the UK Government to commission an investigation led by Robert Francis QC, a medical negligence attorney, which culminated in the publication of the Francis Report in February 2013.2

The investigation led to the discovery of several major issues relating to the hospital’s administration and quality of care. During the inquiry, it was revealed that some patients were left to lie in their own faeces, were not fed properly and were not provided painkillers when necessary. Patient call bells were also often ignored. Furthermore, non-medical reception staff were left to assess the clinical urgency of patients presenting to the Emergency Department.

What were Francis’ Conclusions?

Francis drew a large number of conclusions. We will focus on three here. First, the report notes that there was “an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities” in the hospital. Second, Francis discovered a lack of communication–the staff at the hospital was aware of the issues at hand but were afraid of speaking out about them. In part, this was due to a perception that their concerns would be ignored amidst a climate of fear and culture of bullying which permeated the hospital. Most importantly, achievement of national performance targets and financial goals was prioritized above patient care, as the board strove to achieve ‘Foundation’ status, which has the potential to deliver a significant degree of independence to hospitals in England. Based on these findings, Francis made a number of recommendations–one of which was that patients should be at the center of everything the NHS does. The impact of the report in the UK has been wide-spread, and has triggered a fundamental revaluation of ethics and values within the nation’s healthcare system.

Global Relevance

It is not unreasonable to think that similar events could be repeated within a healthcare system elsewhere in the world. For example, the Institute of Medicine reported that as many as 98,000 Americans die as a result of preventable medical error each year.3 To reflect this, Francis concluded that the events at Mid Staffordshire were ‘not… of such rarity or improbability that it would be safe to assume that it has not been and will not be repeated.’ In addition, Don Berwick former President of the Institute for Healthcare Improvement and former Administrator of the Centers for Medicare and Medicaid Services stated that the concerns highlighted by Francis ‘are not unique to the NHS; they occur in all large health care systems.’

Therefore, it is important to think about how we, as individuals, can prevent such events from recurring. While Francis lists a number of recommendations that can help prevent such situations from occurring, it is up to people on the ground to implement these changes and to ensure that these events do not occur again.

What can we do?

Be honest. The report calls for a ‘Duty of Candour’, requiring all NHS staff to be transparent about mistakes. This is important because patients have a right to know about the standard of care and effective communication is a cornerstone of patient-centred care. A culture of honesty is also more likely to foster a positive culture of improvement, as opposed to sweeping things under the carpet. It is important to note that honesty about mistakes should rarely lead to punishment of the individual, but analysis of where the system has failed followed by appropriate improvements.

In addition, if we witness poor care by others then it is our ethical and professional responsibility to make sure that this is highlighted, escalated and appropriate action is taken. Problems will not be addressed if the correct people aren’t aware of them and whilst it may be uncomfortable, it is essential if we are to make patients the centre of everything we do. This culture of transparency would have positive benefits in any healthcare system across the globe.

Strive for Improvement. As part of the UK Government’s response to the report, they commissioned a number of reviews of specific areas. One of these areas was patient safety and the review was led by Don Berwick.4 It concluded that staff should be empowered to embrace the concept of Quality Improvement (QI). When we identify a problem, instead of complaining, we should propose a solution and work collaboratively with colleagues to pursue it via the QI framework. The Institute for Healthcare Improvement has produced excellent QI eLearning.5 QI is a tool which can empower staff at all levels to implement and evaluate concrete solutions to problems. We should embrace it as a vehicle for positive change in healthcare.

Remember our core values. Most people became involved with healthcare because they wanted to make a difference to people’s lives. Amongst the stresses of the day to day working environment in healthcare, it is easy to lose sight of this core value and focus instead on targets, finances or going home on time. As Francis notes, “management thinking (at Stafford Hospital) was dominated by financial pressures.” The most effective action may be simply to take a step back and consider your actions from your patient’s point of view, and then to think whether you are doing the right thing. As Berwick concludes, we need to “make sure pride and joy in work infuse the NHS,” and I would extend that sentiment to every healthcare system around the world.

Lead by Example. Francis concludes that the example set by leaders is of particular importance to the “common culture and values of the NHS.” However, I would broaden this and argue that all health professionals have an obligation to lead by example. If each of us is seen to go the extra mile by our colleagues, then we will create a self-perpetuating positive cycle of encouragement and improvement. To paraphrase Gandhi, it is up to all of us to “be the change we wish to see.”